Images in infectious diseases: Monkeypox – images of an exhibition

A 35-year-old man who has sex with men (MSM) approached his HIV treating physician by email, because of new scrotal skin lesions (Fig. 1A), he noticed the day before, appearing with urethral discharge and left-sided, enlarged inguinal lymph node. Self-administered doxycycline, due to suspected syphilis, did not improve symptoms. HIV was detected in December 2019, and antiretroviral therapy was immediately started; medical and sexual transmitted infections (STI)-history was unremarkable. Due to COVID-19 isolation, the first clinical examination was deferred to day 11, revealing four increased circular crater-shaped, scrotal skin elevations with central melting (5 × 5 mm; see Fig. 1E) and no further complaints. Laboratory investigations found slightly elevated C-reactive protein (CRP 1.11 mg/dl, nr < 0.5), normal STI check for syphilis, chlamydia, gonococci and trichomonas, but positive Monkeypox DNA from swap (Ct-value = 18.62; in-house modified LightMix Modular Monkeypox Virus-PCR/TibMolBiol, Roche Diagnostics, Mannheim/Germany; Ctvalue ≥ 40 = negative). CD4 cell counts (1007/μl, CD4/ CD8-ratio 0.79) were normal and HIV-RNA undetectable. On day 29, all skin lesions were dry, scarred and inactive and no new vesicles occurred. Therefore, health authorityimposed Monkeypox isolation was finally lifted and patient returned to work as elderly care nurse. Nucleic acid assays and electron microscopy (see Fig. 2) may support clinical Monkeypox diagnosis in MSM context [1]. Best supportive care of lesions will be most frequently treatment for immunocompetent individuals, as specific antiviral therapy is unavailable [2]. Facing case numbers in Germany [3], a high level of suspicion for Monkeypox visual diagnosis is warranted and this presentation of overtime skin lesions may help for individual timing assignment.

approached his HIV treating physician by email, because of new scrotal skin lesions (Fig. 1A), he noticed the day before, appearing with urethral discharge and left-sided, enlarged inguinal lymph node. Self-administered doxycycline, due to suspected syphilis, did not improve symptoms. HIV was detected in December 2019, and antiretroviral therapy was immediately started; medical and sexual transmitted infections (STI)-history was unremarkable.
Due to COVID-19 isolation, the first clinical examination was deferred to day 11, revealing four increased circular crater-shaped, scrotal skin elevations with central melting (5 × 5 mm; see Fig. 1E) and no further complaints. Laboratory investigations found slightly elevated C-reactive protein (CRP 1.11 mg/dl, nr < 0.5), normal STI check for syphilis, chlamydia, gonococci and trichomonas, but positive Monkeypox DNA from swap (Ct-value = 18.62; in-house modified LightMix Modular Monkeypox Virus-PCR/Tib-MolBiol, Roche Diagnostics, Mannheim/Germany; Ctvalue ≥ 40 = negative). CD4 cell counts (1007/μl, CD4/ CD8-ratio 0.79) were normal and HIV-RNA undetectable. On day 29, all skin lesions were dry, scarred and inactive and no new vesicles occurred. Therefore, health authorityimposed Monkeypox isolation was finally lifted and patient returned to work as elderly care nurse.
Nucleic acid assays and electron microscopy (see Fig. 2) may support clinical Monkeypox diagnosis in MSM context [1]. Best supportive care of lesions will be most frequently treatment for immunocompetent individuals, as specific antiviral therapy is unavailable [2]. Facing case numbers in Germany [3], a high level of suspicion for Monkeypox visual diagnosis is warranted and this presentation of overtime skin lesions may help for individual timing assignment.
Acknowledgements To the patient for alert and wonderful photo documentation,-this would merit authorship, but he refused, for understandable discretion interest.
Author contribution AMG and CS wrote the main manuscript text, and CS and HFR prepared Figs. 1 and 2. All the authors reviewed the manuscript.
Funding Open Access funding enabled and organized by Projekt DEAL. This study was funded by Frankfurt University Hospital.

Data availability
The authors confirm that the data supporting the findings of this study were raised from clinical routine in Frankfurt University Hospital outpatient department and are available within this article.

Declarations
Conflict of interest None of the authors reported any conflict of interest in context with this study.

Consent to participate and consent to publish
The patient consents to having the data published.
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